By completing this form you are authorizing Genentox Laboratories LLC dba Nova Diagnostics Laboratories to release your SARS-CoV-2/COVID-19 RT-PCR test results to third party entities such as government offices, the Department of Public Health, your employer and/or the ordering physician.
This authorization will allow Genentox Laboratories LLC dba Nova Diagnostics Laboratories to disclose my SARS-CoV-2/COVID-19 test results with select third parties. I understand this consent is voluntary and that I may refuse to sign. I assume complete and full responsibility to take appropriate action with regards to my test results. Should I have questions or concerns regarding my test results, or a worsening of my condition, I shall promptly seek advice and treatment from an appropriate medical provider.
Medical Information. Any lab test results relating to SARS-CoV-2/COVID-19 testing, including "back to work" recommendations.
Service Dates. Any dates of services rendered from the date I sign this form and one year forward.
Expiration/Effective Dates. This consent will expire one year from the date I sign it. This authorization applies to any lab tests results related to COVID-19 screening/testing after the date of my signature. I may revoke this consent at any time by sending written notice to Genentox Laboratories LLC dba Nova Diagnostics Laboratories.
To the fullest extent permitted by law, I hereby release, discharge and hold harmless Genentox Laboratories LLC dba Nova Diagnostics Laboratories — without limitation — and it's respective officers, directors, employees ,representatives and agents, from any and all claims, liability and damages of whatever kind or nature, a rising out of or in connection with any act or omission relating to my COVID-19 diagnostic test or the disclosure of my COVID-19 test results to a third party.